Abstract

Introduction: The purpose of this survey was to explore the dissemination of flexible ureteroscopy (fURS), shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) in the Italian urological community and to know the real availability of the complex endourological armamentarium all over the country. Materials and methods: An online questionnaire characterizing the case volume/year of upper urinary tract stone treatment and the availability of flexible ureteroscopes (FUs) armamentarium was sent to all urological Italian centers. Results: The survey was sent to 294 urological centers and 146 responded (49.7%). The case volume/year of fURS was the following: <20 cases in 20 centers (13.7%); 20-50 cases in 40 centers (27.4%), >50- <100 cases in 55 centers (37.8%) and >100 cases in 28 centers (19.2%). The case volume/year of SWL was the following: <50 cases in 18 centers (12.3%); >50- <200 cases in 56 centers (36.4%) and >200 cases in 35 centers (24%). In 37 centers (25.3%) SWL was not utilized at all. The case volume/year of PCNL was the following: <10 cases in 20 centers (14%); >10 - <30 cases in 55 centers (30%), >30- < 50 cases in 33 centers(23%), >50- <100 cases in 13 centers (9%) and >100 procedures in 2 centers (1%). However, 24 centers (16%) did not perform any PCNL procedure. Four centers (3%) did not have any FU at the moment of the survey. The availability of FUs was as follows: 1 FU in 21 (14%) centers, 2 FUs in 61 (42%) centers, 3 FUs in 29 (20%) centers, 4 FUs in 13 (9%) centers and ≥5 FUs in 16 (9%) centers. Only 82 (56%) centers had all of their FUs in working condition. Conclusions: This survey succeeded in providing a complete overview on the Italian endourological panorama.

Comments
1

An interesting article because of the data and moreover because of the discussion which touches many aspects of the urological profession.
The authors assume a change that I have observed in Germany already in the 1990s: Big stones become less frequent and small stones are seen more often. The consequence the authorssee, is surprising: “… ultrasound has changed the clinical scenario of kidney stones, allowing their diagnosis at earlier stages when they are relatively small and, consequently, expanding the pool of patients who may benefit from fURS rather than from PCNL.”
But: “What clearly emerges from this survey is that what limits the national disseminationof fURS is the combination of cost in acquisition and maintenance of the
delicate FUs and disposable armamentarium, and the related reimbursement by the national public health care system that, for instance, is very low, especially when compared to the one of PCNL (roughly 50% less).

One would expect that, according to the guidelines EWSL is the method of choice in these cases with small stones. Why this is not happening is also explained in the discussion: “… it has also to be taken into account the fact that in some countries such as Italy, SWL's reimbursement by public health systems according to DRGs is much less remunerative than that it was in the past, and inferior to both fURS and PCNL.” An Italian Urologist has recently told me that the department’s old shock wave machine was not replaced by the administration with the argument that the treatment would not pay off. The national availability of fURS is less than wanted. But it is not only money which turns the world around: If the costs of flexible ureteroscopes limit their use and ESWL offers a low reimbursement, mini PNL would be the less expensive choice, but: “In fact, in the majority of centers the case volume of PCNL was very low or even absent. This is in line with the widespread feeling among the Italian urological community that PCNL is still considered complex and potentially burdened by major complications implying a longer learning curve and more endourological skills to train.”
In essence it seems that the patient does not get what he needs but what is available on the urological supermarket shelves.

An interesting article because of the data and moreover because of the discussion which touches many aspects of the urological profession.
The authors assume a change that I have observed in Germany already in the 1990s: Big stones become less frequent and small stones are seen more often. The consequence the authorssee, is surprising: “… ultrasound has changed the clinical scenario of kidney stones, allowing their diagnosis at earlier stages when they are relatively small and, consequently, expanding the pool of patients who may benefit from fURS rather than from PCNL.”
But: “What clearly emerges from this survey is that what limits the national disseminationof fURS is the combination of cost in acquisition and maintenance of the
delicate FUs and disposable armamentarium, and the related reimbursement by the national public health care system that, for instance, is very low, especially when compared to the one of PCNL (roughly 50% less).
One would expect that, according to the guidelines EWSL is the method of choice in these cases with small stones. Why this is not happening is also explained in the discussion: “… it has also to be taken into account the fact that in some countries such as Italy, SWL's reimbursement by public health systems according to DRGs is much less remunerative than that it was in the past, and inferior to both fURS and PCNL.” An Italian Urologist has recently told me that the department’s old shock wave machine was not replaced by the administration with the argument that the treatment would not pay off. The national availability of fURS is less than wanted. But it is not only money which turns the world around: If the costs of flexible ureteroscopes limit their use and ESWL offers a low reimbursement, mini PNL would be the less expensive choice, but: “In fact, in the majority of centers the case volume of PCNL was very low or even absent. This is in line with the widespread feeling among the Italian urological community that PCNL is still considered complex and potentially burdened by major complications implying a longer learning curve and more endourological skills to train.”
In essence it seems that the patient does not get what he needs but what is available on the urological supermarket shelves.